Early Educator Support, Licensure and

Professional Development Office, Early

Education Unit, Education & Quality Section

Application for Mentor and/or Evaluator

I am interested to (check all that apply): Mentor Evaluate

Personal Information

First Name Middle Initial Last Name
Current Early Childhood Education assignment or other assignment/responsibility:
Mailing Address City Zip Code County
Home Phone Number Cell Number Work
Your E-Mail Address: Work E-mail:
Education and Licensing Information
BA/BS MA/MS Ed. D/Ph. D
Program Major (s)/Minor:
College/University:
Please check the type of license you hold: B-K SP 1 or 2 Preschool Add-on Other (list type):
NC DPI Mentor Teacher training: NO YES If yes, when:
NC Educator Evaluation Process (NCEP) Training, including HomeBase online system: NO YES
If yes, when:
Relevant Work Experience
You may submit a resume with the following information:
Job Title Employer Employer’s Address Date of Employment

Application Check List (check all that apply)

Current Resume 3 Reference Letters Requested
Completed Response Questions Copies of Performance Evaluations Attached
Copy of Teaching License Attached Copy of Evaluator Training Certificate Attached
Copy of Mentor Training Certificate Attached
Mail completed application to the appropriate Lead Project Coordinator :
EAST: EESLPD Office at East Carolina University WEST: EESLPD Office at UNC Charlotte
Deborah Sapperstein Anne-Marie de Kort-Young
Department of Child Development & College of Education, 323C
Family Relations UNC-Charlotte
Rivers Building/Mailstop 505 9201 University City Boulevard
Greenville, NC 27858 Charlotte, NC 28223-0001
Signature: ______Date: ______/______/______

EESSLPD Office: County/Regional Map and Staff Contacts

Early Educator Support, Licensure and

Professional Development Office, Early

Education Unit, Education & Quality Section

Mentor and/or Evaluator Response Questions

Thank you for your interest in becoming a Mentor and/or Evaluator for initially licensed Early Childhood Education teachers working in nonpublic schools/programs in North Carolina. In the space provided, write a response to each of these questions related to the role(s) you are applying for (there are no right or wrong answers). Please attach this form to your application.

1. What skills do you think a Mentor and/or Evaluator should have in order to establish a productive helping relationship?

2. What communication skills should a Mentor and/or Evaluator demonstrate?

3. As a Mentor and/or Evaluator you must be able to demonstrate knowledge of the diverse roles of the mentoring/coaching relationship. What does this statement mean to you?

4. As a Mentor and/or Evaluator what documentation and strategies would you use for promoting growth in the beginning teacher or initially licensed teacher?

Your name (please print) ______

Your signature (please sign)______Date______

Mentor/Evaluator Applicant’s Name:

Work Number: Mobile/Cell Number:

Applying to become (check all that apply): Mentor Evaluator

1.  How long and in what capacity have you known the applicant?

2.  The EESLPD Office is looking for professionals in a Mentor and/or Evaluator role who are empathic, who build friendships easily, who are themselves models of effective teaching, and who discuss teaching with fluency. Briefly give your assessment of the applicant’s ability to fill this role.

3.  Please check one of the following statements and sign below:

_____I recommend this person as a Mentor. She/he meets the following conditions for becoming a Mentor:

 Three years of successful teaching experience

 Positive/favorable evaluations for the past 3 years

 Evidence of innovation as an Early Childhood educator

 Commitment to the helping role of a potential mentor

_____I do not recommend this person to become a Mentor of beginning early childhood education teachers at the present time.

_____I recommend this person as an Evaluator. She/he meets the following conditions for becoming an Evaluator:

 Three years of successful leadership in Early Childhood Education

 Experience in evaluating, supervising, mentoring/coaching teachers

 Evidence of innovation as an Early Childhood educator/professional

 Commitment to the helping role of a potential evaluator

_____I do not recommend this person to become an Evaluator of beginning early childhood education teachers at the present time.

4. Please comment concerning your over-all recommendations of this person as a Mentor and/or Evaluator of beginning or initially licensed teachers.

Name of Person completing the Recommendation: (please print):
Title: Telephone/Cell number(s): E-Mail:
Relationship to the applicant:
Signature/Title: Date: